Dual ipsilateral renal transplantation from a non-heart-beating donor

A case is described where both kidneys from non-heart-beating (expanded criteria) donors were dual transplanted ipsilaterally. Although both kidneys passed viability tests on the Newcastle machine preservation system and biomarkers' evaluation, there were logistical issues where the cold ischaemic time was too protracted necessitating the transplantation of both kidneys into one recipient. The recipient had satisfactory outcome with the Cockcroft-Gault creatinine clearance of 72.47 (36.29 ml/min individual kidney glomerular filtration rate) suggesting beneficial use of sub-optimal organs to improve outcome.     

Liver transplantation from an uncontrolled non-heart-beating donor maintained on extracorporeal membrane oxygenation

Liver transplantation, a definitive treatment for end-stage liver disease, has achieved excellent results. However, potential recipients on the waiting list outnumber donors. To expand the donor pool, marginal grafts from older donors, steatotic livers, and non-heart-beating liver donors (NHBD) have been used for transplantation. Reducing the warm ischemia time of NHBD is the critical factor in organs preservation. Liver transplantation using grafts from NHBD have been reported to display a high incidence of primary graft nonfunction and biliary complications. The authors report a liver graft donor who was maintained on extracorporeal membrane oxygenation (ECMO) after successful cardiopulmonary resuscitation. Core body temperature was 5 degrees C. Procurement of the liver using a rapid flush technique was performed 4 hours after instituting ECMO. Graft function recovered fully after transplantation. In conclusion, ECMO may be used to reduce warm ischemia time in liver grafts obtained from uncontrolled NHBD, thereby increasing graft salvage rates.     

Liver transplantation from controlled non-heart-beating donors

BACKGROUND: The use of organs from non-heart-beating donors (NHBDs) has been proposed as one way to increase the donor pool. However, few centers have transplanted livers from NHBDs. We report here the results of 19 liver transplants from controlled NHBDs. METHODS: From January 1993 through August 1999, 364 liver transplantations were performed from heart-beating donors (HBDs) and 19 liver transplantations were performed from NHBDs. Donor and recipient characteristics, posttransplant complications, and patient and allograft survival were compared. RESULTS: No differences in hepatic artery, portal vein, or biliary complications were noted between the groups. However, the rate of primary nonfunction was higher in recipients of livers from NHBDs (10.5% vs. 1.3%; P = .04). No difference in patient survival was seen between recipients of NHBDs or HBDs (72.6% vs. 84.8%; P =.36); however, allograft survival was lower in recipients who received livers from NHBDs (53.8% vs. 80.9%; P =.007). CONCLUSIONS: Liver transplantation from controlled NHBDs results in similar patient survival and post-transplant complications. However, primary nonfunction was higher and allograft survival was less in recipients of livers from NHBDs. The results of liver transplantation from controlled NHBDs are encouraging and should continue to be cautiously pursued as one way to help alleviate the current shortage of donor livers.     

Successful segmental auxiliary liver transplantation from a non-heart-beating donor: implications for split-liver transplantation

BACKGROUND: Liver transplantation (LT) using grafts from non-heart-beating donors (NHBDs) has been shown to be a successful practice. Recently reported primary nonfunction rates are similar to those of LT using grafts from brain-dead donors. METHOD: We report the use of an NHBD liver, which was cut into a right-lobe graft and implanted as an auxiliary partial orthotopic liver transplant for acute liver failure in a 11-year-old child. The warm ischemia time was 21 minutes, and the cold ischemia was 8 hours. RESULTS: Initial graft function was excellent, and the child is well, with normal liver function 2 months posttransplant. CONCLUSION: Reduction and splitting of livers from NHBDs for transplantation is a realistic option, provided there is careful selection of the graft.     

Cadaveric renal transplantation from a non-heart-beating pediatric donor into adult recipients

INTRODUCTION: The use of cadaveric pediatric kidneys has been suggested as a means to overcome organ shortage, but is debated because of technical complications and an increased incidence of functional allograft impairment. METHODS: We experienced 2 cases of cadaveric renal transplantation from a non-heart-beating pediatric donor. RESULTS: In our cases, transplanted kidneys achieved good graft function and proteinuria due to glomerulosclerosis was not recognized. CONCLUSION: Previous reports indicate that in transplantation from pediatric donors into adults recipients, glomerular sclerosis occurs as the reason for impairment of grafts. Further, cadaveric renal transplantation from a non-heart-beating donor has a warm ischemia time and an increased risk of hyperfiltrated injury and graft failure. If transplantation of pediatric kidneys into adults from a non-heart-beating donor is performed, BMI and BSA must be carefully considered in the selection of recipients in order to avoid imbalance between nephron supply and metabolic demands and to insure successful, healthy grafts.     

Liver transplantation from Maastricht category 2 non-heart-beating donors

BACKGROUND: The demand for liver transplantation has increasingly exceeded the supply of cadaver donor organs. Non-heart-beating donors (NHBDs) may be an alternative to increase the cadaver donor pool. METHODS: The outcome of 20 liver transplants from Maastricht category 2 NHBDs is compared with 40 liver transplants from heart-beating donors (HBDs). After unsuccessful cardiopulmonary resuscitation (CPR), cardiopulmonary support (CPS) with simultaneous application of chest and abdominal compression (n=6), and cardiopulmonary bypass (CPB; n=14), which was hypothermic (n=7) or normothermic (n=7), were used to preserve the organs from NHBDs. Factors that may influence the outcome of livers from Maastricht category 2 NHBDs were also investigated. RESULTS: With a minimum follow-up of 2 years, actuarial patient and graft survivals with livers from Maastricht category 2 NHBDs were 80% and 55%, respectively. Transplantation of organs from these donors was associated with a significantly higher incidence of primary nonfunction, biliary complications, and more severe initial liver dysfunction compared with livers from HBDs. Graft survival was 83% in livers from NHBDs preserved with CPS and 42% in those maintained with CPB. No graft failed if the duration of warm ischemia did not exceed 130 min with CPR or CPS, and if the period of CPB did not surpass 150 min when this method was used after CPR, regardless if it was hypothermic or normothermic. CONCLUSION: Livers from Maastricht type 2 NHBDs may be used for transplantation if the period of warm ischemia during CPR or CPS does not exceed 130 min. Hypothermic or normothermic CPB after CPR preserves liver viability for an additional 150 min.     

Innovative pulmonary preservation of non-heart-beating donor grafts in experimental lung transplantation.

OBJECTIVE: Lung transplantation is limited by scarcity of donor organs. Lung retrieval from non-heart-beating donors (NHBD) might have the potential to extend the donor pool and has been reported recently. However, no studies in NHBD exist using the novel approach of retrograde preservation with Perfadex solution. METHODS: Asystolic heparinized pigs (n = 5/group) were continuously ventilated for 90, 180 or 300 min of warm ischemia. Lungs were then retrogradely preserved with Perfadex and stored at 4 degrees C in inflation. After 3 h of additional cold ischemia, left lung transplantation was performed. Hemodynamics, pO(2)/F(i)O(2) and dynamic compliance were monitored for 5 h. Intrapulmonary lung water was determined by both global wet-to-dry lung weight ratio (W/D ratio) and standard stereological examination of relative volume fractions of intraalveolar edema. All results were compared to sham-operated controls and to lungs obtained from standard heart-beating donors after retrograde preservation with Perfadex and 27 h of cold ischemia. Statistics comprised ANOVA analysis with repeated measures and Mann-Whitney tests. RESULTS: No mortality was observed. During flush preservation of NHBD lungs, continuous elimination of blood clots via the pulmonary artery was observed. Oxygenation, compliance, intraalveolar edema fraction and W/D ratio were comparable between groups, whereas PVR was significantly lower in sham-controls. CONCLUSIONS: Use of NHBD lungs is feasible and results in similar postischemic outcome when compared to sham-controls and standard preservation procedures even after 5 h of pre-harvest warm ischemia. Especially, the NHBD with high-risk constellations for intravascular coagulation might benefit from retrograde preservation by elimination of thrombi from the pulmonary circulation. This innovative technique might also be considered in situations, where brain-dead organ donors become hemodynamically unstable prior to onset of organ harvest. Further trials with longer warm and cold ischemic periods are initiated to further elucidate this promising approach of donor pool expansion.     

L-arginine reduces liver and biliary tract damage after liver transplantation from non-heart-beating donor pigs

BACKGROUND: To evaluate whether L-arginine reduces liver and biliary tract damage after transplantation from non heart-beating donor pigs. METHODS: Twenty-five animals received an allograft from non-heart-beating donors. After 40 min of cardiac arrest, normothermic recirculation was run for 30 min. The animals were randomly treated with L-arginine (400 mg x kg(-1) during normothermic recirculation) or saline (control group). Then, the animals were cooled and their livers were transplanted after 6 hr of cold ischemia. The animals were killed on the 5th day, liver damage was assessed on wedged liver biopsies by a semiquantitative analysis and by morphometric analysis of the necrotic areas, and biliary tract damage by histological examination of the explanted liver. RESULTS: Seventeen animals survived the study period. The histological parameters assessed (sinusoidal congestion and dilatation, sinusoidal infiltration by polymorphonuclear cells and lymphocytes, endothelitis, dissociation of liver cell plates, and centrilobular necrosis) were significantly worse in the control group. The necrotic area affected 15.9 +/- 14.5% of the liver biopsies in the control group and 3.7 +/- 3.1% in the L-arginine group (P<0.05). Six of eight animal in the control group and only one of eight survivors in the L-arginine group developed ischemic cholangitis (P<0.01). L-Arginine administration was associated with higher portal blood flow (676.9 +/- 149.46 vs. 475.2 +/- 205.6 ml x min x m(-2); P<0.05), higher hepatic hialuronic acid extraction at normothermic recirculation (38.8 +/- 53.7% vs. -4.2 +/- 18.2%; P<0.05) and after reperfusion (28.6 +/- 55.5% vs. -10.9 +/- 15.5%; P<0.05) and lower levels of alpha-glutation-S-transferase at reperfusion (1325 +/- 1098% respect to baseline vs. 6488 +/- 5612%; P<0.02). CONCLUSIONS: L-Arginine administration during liver procurement from non heart beating donors prevents liver and biliary tract damage.     

Liver transplantation using non-heart-beating donors: Belgian experience

Mortality on liver transplantation (OLT) waiting lists has increased dramatically. Until recently, non-heart-beating donors (NHBD) were not considered suitable for OLT, because of a higher risk of primary graft nonfunction (PNF) and biliary strictures. However, recent experimental/clinical evidence has indicated that NHBD-OLT is feasible when the period of warm ischemia is short. PURPOSE: To characterize the results of NHBD-OLT in Belgium, a survey was sent to all Belgian OLT centers. RESULTS: Between January 2003 and November 2005, 16 livers originating from NHBD were procured and transplanted. The mean donor age was 48.8 years, including 9 males and 7 females with mean time of stop-therapy to cardiac arrest being 18 minutes and from cardiac arrest to liver cold perfusion, 10.5 minutes. Mean recipient age was 52.2 years including 12 males and 4 females. Mean cold ischemia time was 7 hours 15 minutes. No PNF requiring re-OLT was observed. Mean post-OLT peak transaminase was 2209 IU/L, which was higher among imported versus locally procured grafts. Biliary complications occurred in 6 patients requiring re-OLT (n = 2), endoscopic treatment (n = 2), surgical treatment (n = 1), or left untreated (n = 1). These tended to be more frequent after prolonged warm ischemia. Graft and patient survivals were 62.5% and 81.3%, respectively, with a follow-up of 3 to 36 months. CONCLUSION: This survey showed acceptable graft/patient survivals after NHBD-LT. The NHBD-liver grafts suffered a high rate of ischemic injury and biliary complications and therefore should be used carefully, namely with no additional donor risk factors, lower risk recipients, and short cold/warm ischemia.     

Liver transplantation from non-heart-beating donors: current status and future prospects.

Liver transplantation is the treatment of choice for many patients with acute and chronic liver failure, but its application is limited by a shortage of donor organs. Donor organ shortage is the principal cause of increasing waiting lists, and a number of patients die while awaiting transplantation. Non-heart-beating donor (NHBD) livers are a potential means of expanding the donor pool. This is not a new concept. Prior to the recognition of brainstem death, organs were retrieved from deceased donors only after cardiac arrest. Given the preservation techniques available at that time, this restricted the use of extrarenal organs for transplantation. In conclusion, after establishment of brain death criteria, deceased donor organs were almost exclusively from heart-beating donors (HBDs). To increase organ availability, there is now a resurgence of interest in NHBD liver transplantation. This review explores the basis for this and considers some of the published results.     

Short-term inhaled nitric oxide in canine lung transplantation from non-heart-beating donor

BACKGROUND: Use of lungs harvested from non-heart-beating donors (NHBDs) would increase the pulmonary donor pool; however, this strategy would have higher risk of early postoperative graft dysfunction due to unavoidable warm ischemic time. We evaluated the effects of short-term inhaled nitric oxide (NO) during reperfusion in canine left single-lung allotransplantation from a non-heart-beating donor. METHODS: The donor dogs were sacrificed without heparinization and left at room temperature for 3 hours. Then, recipient dogs received a left single-lung allotransplantation. After implantation, the right bronchus and pulmonary artery were ligated. In group 1 (n = 6), NO gas was administered continuously at a concentration of 40 parts per million throughout a 6-hour assessment period. In group 2 (n = 6), NO gas was administered for the initial 1 hour during reperfusion. In group 3 (n = 6), nitrogen gas was administered for control. RESULTS: Groups treated with NO exhibited lower pulmonary vascular resistance, as well as improved survival and oxygenation. There was no significant difference in these parameters between group 1 and group 2. Myeloperoxidase activity was significantly lower in NO-treated groups. CONCLUSIONS: Inhaled NO during reperfusion is beneficial in lung transplantation from non-heart beating donors. The beneficial effect is obtained mainly during the first hour of reperfusion.     

Lung transplantation with uncontrolled non-heart-beating donor. Review

The discrepancy between organ availability and the increasing amount of patients on the waiting list has prompted the development of medical strategies to increase the usable organs, including the search for alternative sources of donation, organ optimization and extension of the criteria for donation. The recovery of lungs from non-heart-beating donors (NHBD) is a concept in which death is declared based on cardiopulmonary criteria rather than the currently used definition of "brain death." Obtaining NHBD lungs is currently practiced in many centers. In this review we discuss the current state of lung transplantation from uncontrolled NHBD.     

Liver transplantation from controlled non-heart-beating donors: an increased incidence of biliary complications

BACKGROUND: Hepatic allografts from non-heart-beating donors (NHBD) have been cited as a means to expand the supply of donor livers. Concern exists that donor warm ischemic time in addition to subsequent cold ischemia-reperfusion injury may result in damage to sensitive cell populations within the liver. Because the biliary epithelium is sensitive to ischemia-reperfusion injury, the authors surmised that an increased incidence of biliary complications might occur among recipients of an NHBD allograft. METHODS: This study was a retrospective evaluation of NHBD recipients compared to a group of heart-beating donor (HBD) recipients from a single institution. RESULTS: Fifteen patients received a hepatic allograft from a controlled NHBD donor. NHBD and HBD (n=221) graft survival did not differ at 1 (71.8% vs. 85.4%, P=0.23) or 3 years (71.8% vs. 73.9%, P=0.68). Patient survival at 1 (79% vs. 90.9%, P=0.16) and 3 years (79.0% vs. 77.7%, P=0.8) was also similar. Major biliary complications occurred in five (33.3%) NHBD recipients; 66.6% of the NHBD biliary complications consisted of intrahepatic strictures versus 19.2% among HBD recipients (P<0.01). Major biliary complications in the NHBD recipients resulted in multiple interventional procedures, retransplantation, and death. CONCLUSIONS: Donor warm ischemic time may predispose hepatic allografts to an increased incidence of ischemic type strictures. Although graft and patient survival was similar to a cohort of HBD recipients, caution is urged with the use of these organs.